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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198200623
Report Date: 09/30/2021
Date Signed: 09/30/2021 12:23:13 PM

Document Has Been Signed on 09/30/2021 12:23 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME:DEWEY HOME INC.FACILITY NUMBER:
198200623
ADMINISTRATOR:RAFAEL BRAVOFACILITY TYPE:
740
ADDRESS:2127 DEWEY STREETTELEPHONE:
(310) 458-8006
CITY:SANTA MONICASTATE: CAZIP CODE:
90405
CAPACITY: 6CENSUS: 2DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Ivan BravoTIME COMPLETED:
12:35 PM
NARRATIVE
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On 9/30/2021/21, Licensing Program Analysts (LPA) Stephanie Cifuentes and Gail Johnson conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ivan Bravo and explained the purpose of today’s visit. The facility is an RCFE licensed for six (6) non- ambulatory client. Currently, there are (2) two non-ambulatory residents residing in the facility, all 60 or older.

The facility is a one-story structure located in a residential neighborhood. It consists of the following: four (4) resident bedrooms, with three bathrooms, living room, dining room, kitchen, outside laundry room. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A 2-day supply perishable and 7-day supply of non-perishable foods are present in the facility.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for client personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Cleaning supplies and toxins, were stored in the laundry room and sharps objects are stored in locked kitchen drawers, locked and not accessible to clients. The kitchen was inspected and there is a 2-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Two (2) fully charged fire extinguishers were kitchen and backyard.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, All mandated inspection control posters were posted.

The following deficiencies were noted during the visit:
At 11:17AM water temperature in kitchen and bathroom 1 was over 143 degrees Farenheit.
See 809-D

Advisories are on attached 9102

An exit interview was conducted, and a copy of this report was provided to Ivan Bravo, Administrator.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2021 12:23 PM - It Cannot Be Edited


Created By: Stephanie Cifuentes On 09/30/2021 at 11:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: DEWEY HOME INC.
FACILITY NUMBER: 198200623

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above the hot water temperature measured 143.1F which poses an immediate safety risk to persons in care.
POC Due Date: 10/01/2021
Plan of Correction
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Admisntrator agreed to lower water boiler and monitor temperature so it does not go above 120F. POC was cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva M Alvarez
LICENSING EVALUATOR NAME:Stephanie Cifuentes
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021


LIC809 (FAS) - (06/04)
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